Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Allergy Testing
Allergy testing may be considered medically necessary in the diagnosis of allergies by ANY ONE of the following techniques:
- Direct Skin Test with ANY ONE of the following techniques:
- Percutaneous (scratch, prick, or puncture) testing when IgE-mediated reactions occur with ANYONE of the following indications:
- Inhalants; or
- Foods; or
- Hymenoptera (stinging insects); or
- Specific drugs (penicillin's and macromolecular agents).
- Intracutaneous (intradermal) testing when IgE-mediated reactions occur with ANY ONE of the following indications:
- Inhalants; or
- Hymenoptera (stinging insects); or
- Specific drugs (penicillin's and macromolecular agents.
A cumulative total of 70 percutaneous or 40 intracutaneous tests allowed per benefit year.
- Patch test (application test) for diagnosing contact dermatitis or eosinophilic esophagitis; or
- Photo patch test for diagnosing a photo-allergy (e.g., photo-allergic contact dermatitis); or
- Bronchial challenge tests to diagnose ANY ONE of the following:
- To identify new allergens for which skin or blood testing has not been validated; or
- Skin testing is unreliable; or
- Oral challenge tests for ANY of the following:
- Food or other substances (i.e. additives or preservatives); or
- Drugs when ALL of the following are met:
- An allergy to multiple classes of drugs within a drug category is suspected (i.e. allergic to penicillin, and cephalosporins); and
- There is no effective alternative drug; or
- Treatment with that drug is essential.
Allergy testing not meeting the criteria above is considered not medically necessary.
Procedure Codes
| 95004 | 95017 | 95018 | 95024 | 95027 | 95028 | 95044 |
| 95052 | 95070 | 95076 | 95079 | | | |
Skin Endpoint Titration (SET) is considered experimental/investigational and therefore noncovered, for all indications because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Allergy Testing Methods
Allergy testing methods are considered not medically necessary with ANYONE of the following:
- Cytotoxic food testing; or
- Provocative testing; or
- Sublingual (antigens prepared for sublingual administration); or
- Mucous Membrane Test (e.g., direct nasal, ophthalmic).
Procedure Codes
Professional Statements and Societal Positions Guidelines
National Institute of Allergy and Infection Diseases
4.2.2.2. Intradermal Tests Guideline 5: The EP recommends that intradermal testing should not be used to make a diagnosis of FA.
ND Committee Review
Internal Medical Policy Committee 9-26-2019 - Effective November 04, 2019
Internal Medical Policy Committee 5-19-2020 - Effective July 06, 2020
Internal Medical Policy Committee 01-19-2021 Coding Update - Effective March 01, 2021
- Removed procedure code 95071
Internal Medical Policy Committee 01-20-2022 Coding update - Effective March 07, 2022
- Removed Leukocyte histamine release and
- Removed procedure code 86343
Internal Medical Policy Committee 11-29-2022 Coding update - Effective January 02, 2023
- Added diagnosis codes K90.49; Z91.018
Internal Medical Policy Committee- 3-23-2023 Coding update - Effective May 01, 2023
- Removed diagnosis code R05; and
- Added diagnosis code R05.3
Internal Medical Policy Committee 1-14-2025 Revision with Coding update - Effective March 03, 2025
- Removed Diagnosis Codes: J33.0; J33.8; J34.3; and K20.0 and
- Added Covered Diagnosis Codes for Procedure Codes 95004; 95017; 95018; 95024; 95027; 95028: T42.0X5A; T42.0X5D; T42.0X5S; T42.1X5A; T42.1X5S; Z91.014; Z91.040; & Z91.041; and
- Added Covered Diagnosis Codes for Procedure Code 95044: L24.A1; L24.A2; L50.1; & L50.6; and
- Added Covered Diagnosis Codes for Procedure Code 95052: L56.4; L56.5; & L56.9; and
- Added Covered Diagnosis Codes for Procedure Codes 95076, and 95079: L27.0; L27.2; L27.8; L27.9; T36.1X5A; T36.1X5D; T36.1X5S; T36.2X5A; T36.2X5D; T36.2X5S; T36.3X5A; T36.4X5A; T36.4X5D; T36.4X5S; T36.5X5A; T36.5X5D; T36.5X5S; T36.6X5A; T36.7X5A; T36.7X5D; T36.7X5S; T36.8X5A; T36.8X5D; T36.8X5S; T37.0X5A; T37.0X5D; T37.0X5S; T37.1X5A; T37.1X5D; T37.1X5S; T37.4X5A; T37.4X5D; T37.4X5S; T37.5X5A; T37.5X5D; T37.5X5S; T38.0X5A; T38.0X5D; T38.0X5S; T38.1X5A; T38.1X5D; T38.1X5S; T38.2X5A; T38.2X5D; T38.2X5S; T38.3X5A; T38.3X5D; T38.3X5S; T38.4X5A; T38.4X5D; T38.4X5S; T38.5X5A; T38.5X5D; T38.5X5S; T38.6X5A; T38.6X5D; T38.6X5S; T38.7X5A; T38.7X5D; T38.7X5S; T38.815A; T38.815D; T38.815S; T38.895A; T38.895D; T38.895S; T38.995A; T38.995D; T38.995S; T39.015A; T39.015D; T39.015S; T39.095A; T39.095D; T39.095S; T39.1X5A; T39.1X5D; T39.1X5S; T39.1X5A; T39.1X5D; T39.1X5S; T39.2X5A; T39.2X5D; T39.2X5S; T39.315A; T39.315D; T39.315S; T39.4X5A; T39.4X5D; T39.4X5S; T40.0X5A; T40.0X5D; T40.0X5S; T40.3X5A; T40.3X5D; T40.3X5S; T40.415A; T40.415D; T40.415S; T40.425A; T40.425D; T40.425S; T40.495A; T40.495D; T40.495S; T40.5X5A; T40.5X5D; T40.5X5S; T40.715A; T40.715D; T40.715S; T40.725A; T40.725D; T40.725S; T42.2X5A; T42.2X5D; T42.2X5S; T42.3X5A; T42.3X5D; T42.3X5S; T42.4X5A; T42.4X5D; T42.4X5S; T42.5X5A; T42.5X5D; T42.5X5S; T43.015A; T43.015D; T43.015S; T43.025A; T43.025D; T43.025S; T43.1X5A; T43.1X5D; T43.1X5S; T43.3X5A; T43.3X5D; T43.3X5S; T43.4X5A; T43.4X5D; T43.4X5S; T43.615A; T43.615D; T43.615S; T43.625A; T43.625D; T43.625S; T43.655A; T43.655D; T43.655S; T50.Z15A; T50.Z15D; T50.Z15S; T63.024A, T63.024D; T63.024S; T78.04XA; T78.04XD; T78.04XS; T50.Z15S; Z91.014; Z91.030; Z91.040; and Z91.048; and
- Changed medically necessary to experimental/investigational for Skin Endpoint Titration (SET) section.
Internal Medical Policy Committee 11-6-2025 Coding-Effective January 01, 2026
Added Diagnosis Codes for Procedure Codes 95004, 95017, 95018, 95024, 95027, 95028: T78.070A, T78.070D, T78.070S, T78.071A, T78.071D, T78.071S, T78.079A, T78.079D, T78.079S, T78.080A, T78.080D, T78.080S, T78.081A, T78.081D, T78.081S, T78.089A, T78.089D, T78.089S, T78.110A, T78.110D, T78.110S,T78.111A, T78.111D, T78.111S, T78.119A, T78.119D, T78.119S, T78.120A, T78.120D, T78.120S, T78.121A, T78.121D, T78.121S, T78.129A, T78.129D, T78.129S, T78.19XA, T78.19XD,T78.19XS
Removed Diagnosis Codes for Procedure Codes 95004, 95017, 95018, 95024, 95027, 95028: T78.07XA, T78.07XD, T78.07XS, T78.08XA, T78.08XD, T78.08XS, T78.1XXA, T78.1XXD, T78.1XXS
Added Diagnosis Codes for Procedure Codes 95076, 95079: T78.070A, T78.070D, T78.070S, T78.071A, T78.071D, T78.071S, T78.079A, T78.079D, T78.079S, T78.080A, T78.080D, T78.080S, T78.081A, T78.081D, T78.081S, T78.089A, T78.089D, T78.089S, T78.110A, T78.110D, T78.110S,T78.111A, T78.111D, T78.111S, T78.119A, T78.119D, T78.119S, T78.120A, T78.120D, T78.120S, T78.121A, T78.121D, T78.121S, T78.129A, T78.129D, T78.129S, T78.19XA, T78.19XD,T78.19XS, T36.9X5A, T36.5X5D, T36.9X5A
Removed Diagnosis Codes for 95076, 95079: T78.07XA, T78.07XD, T78.07XS, T78.08XA, T78.08XD, T78.08XS, T78.1XXA, T78.1XXD, T78.1XXS
Updated References
Internal Medical Policy Committee 12-16-2025 -Revision- Effective March 01, 2026
Updated Criteria
Added Literature
Internal Medical Policy Committee 6-09-2026 Coding-Effective January 01, 2026
Removed Termed Diagnosis Codes: Z91.011, Z91.012
Added Updated Diagnosis codes: Z91.0110, Z91.0111, Z91.0112, Z91.0120, Z91.0121, Z91.0122
